LEAH ALESNA REYES, ROSE NAHDJA, JOHNNY, and minors LLOYD and KRISTINE, all surnamed REYES,

represented by their mother, LEAH ALESNA REYES vs. SISTERS OF MERCY HOSPITAL, SISTER ROSE
PALACIO, DR. MARVIE BLANES, and DR. MARLYN RICO
G.R. No. 130547
October 3, 2000
MENDOZA, J.
Nature: Petition for review under Rule 42

Facts:
Jorge Reyes was the husband and father of the petitioners. Five days before his death, he suffered
from recurring fever with chills. He sought a doctor after the home medication he took (analgesic,
antipyreptic, and antibiotics) failed. On January 8, 1987, he was brought to Mercy Community Clinic and
was attended to by Dr. Marlyn Rico, the resident and admitting physician on duty. She gave Jorge a
physical examination and noted his medical history. She noted that at the time of admission, Jorge was
conscious, ambulatory, oriented, coherent, and with respiratory distress. She suspected Jorge had typhoid
fever since it was prevalent in the area at that time. Dr. Marlyn Rico then ordered a Widal Test (test for
typhoid fever) on Jorge, as well as blood count, routine urinalysis, stool examination, and malarial smear.
An hour later, the results showed that Jorge was positive for typhoid fever. Upon ending her shift at
5:00pm, Dr. Rico endorsed Jorge to Dr. Marvie Blanes. At around 6pm, Dr. Marvie Blanes also conducted
a medical exam on Jorge and came up with the same conclusion. She then ordered a compatibility test
with the antibiotic chloromycetin on Jorge. The test was administered by nurse Josephine Pagente, who
also gave Jorge a dose of triglobe. There was no adverse reaction by the patient to chloromycetin, so Dr.
Blanes ordered the first 500 milligrams of this antibiotic administered on Jorge at around 9pm. A second
dose was administered three hours later just before midnight. At around 1am, January 9, 1987, Dr. Blanes
was called because Jorge’s temperature rose to 41 deg. Cel. He also experienced chills and exhibited
respiratory distress, nausea, vomiting, and convulsions. Dr. Blanes put him under oxygen, used a suction
machine and administered hydrocortisone to ease the convulsions. When Jorge regained consciousness,
Dr. Blanes asked if he had a previous heart ailment of suffered chest pains in the past. Jorge said no. fifteen
minutes later, he began vomiting, and his convulsions returned. Dr. Blanes re-applied the emergency
measures previously done, and administered valium. Jorge did not respond to the treatment and slipped
into cyanosis, a bluish or purplish discoloration of the skin or mucous membrane due to deficient
oxygenation of the blood. At around 2am, Jorge died at 40 y.o. the cause of death was ventricular
arrythemia secondary to hyperpyrexia and typhoid fever.
Petitioners filed an action for damages against the hospital, its director Sister Rose Palacio, Dr.
Blanes, Dr. Rico, and Mercy Community Clinic. They claim that Jorge died due to the wrongful
administration of chloromycetin; that the respondent doctors failed to exercise due care and diligence in
performing the Widal Test, and failing to conduct sufficient tests on the patient’s compatibility with
chloromycetin.
Witness for the petitioner Dr. Apolinar Vacalares testified that he performed the autopsy on Jorge,
but did not open the skull. Upon examination, he found that the gastro-intestinal tract was normal and
without any ulceration or enlargement of the nodules. He concluded that Jorge did not die of typhoid
fever, and also stated that he had not seen a patient die of typhoid fever within five days from the onset
of the disease. Witnesses for the respondents Dr. Peter Gotiong and Dr. Ibarra Panopio, were experts in
microbiology and infectious diseases, and pathology, respectively. Dr. Gotiong testified that the patient’s
history and positive Widal Test results make him suspect the patient had typhoid fever. As to the absence
of ulceration, he said that the hyperplasia in the intestines of a typhoid victim may be microscopic. He
also noted that since the toxic effect of the typhoid fever may lead to meningitis, the autopsy should have
included an examination of the brain. Dr. Panopio agreed with the testimony of Dr. Gotiong. He said that
the autopsy was incomplete, and thus inconclusive.
RTC ruled in favor of the respondents noting res ipsa loquitur cannot apply. CA affirmed the ruling.

Issue:
Whether or not the doctrine of res ipsa loquitur is applicable in determining if the respondents
were negligent in conducting the tests, in their diagnosis, and in administering the chloromycetin.

Held:
NO. The doctrine of res ipsa loquitur cannot apply because the alleged failure to observe due care
in the cause of death of Jorge was not immediately apparent and required expert opinion.

Ratio:
Medical Malpractice, defined and nature
Petitioner’s action is for medical malpractice. This is a particular form of negligence which consists
in the failure of a physician or surgeon to apply to his practice of medicine that degree of care and skill
which is ordinarily employed by the profession generally, under similar conditions, and in like
surrounding circumstances. In order to successfully pursue such a claim, a patient must prove that the
physician or surgeon either failed to do something which a reasonably prudent physician or surgeon
would have done, or that he or she did something that a reasonably prudent physician or surgeon
would not have done, and that the failure or action caused injury to the patient. There are thus
four elements involved in medical negligence cases, namely: duty, breach, injury, and
proximate causation. In the present case, there is no doubt that a physician-patient relationship existed
between respondent doctors and Jorge Reyes. Respondents were thus duty-bound to use at least the
same level of care that any reasonably competent doctor would use to treat a condition under
the same circumstances. Its breach of this duty which constitutes actionable malpractice. As to this
aspect of medical malpractice, the determination of the reasonable level of care and the breach thereof,
expert testimony is essential. Inasmuch as the causes of the injuries involved in malpractice actions are
determinable only in the light of scientific knowledge, it has been recognized that expert testimony
is usually necessary to support the conclusion as to causation.

Res Ipsa Loquitur

There is a case when expert testimony may be dispensed with, and that is under the doctrine of
res ipsa loquitur.
Although generally, expert medical testimony is relied upon in malpractice suits to prove that a
physician has done a negligent act or that he has deviated from the standard medical procedure, when
the doctrine of res ipsa loquitor is availed by the plaintiff, the need for expert medical testimony is
dispensed with because the injury itself provides the proof of negligence. The reason is that the general
rule on the necessity of expert testimony applies only to such matters clearly within the domain of medical
science, and not to matters that are within the common knowledge of mankind which may be testified to
by anyone familiar with the facts. Ordinarily, only physicians and surgeons of skill and experience are
competent to testify as to whether a patient has been treated or operated upon with a reasonable
degree of skill and care. However, testimony as to the statements and acts of physicians and surgeons,
external appearances, and manifest conditions which are observable by any one may be given by
non-expert witnesses. Hence, in cases where the res ipsa loquitur is applicable, the court is
permitted to find a physician negligent upon proper proof of injury to the patient, without the aid of
expert testimony, where the court from its fund of common knowledge can determine the proper
standard of care. Where common knowledge and experience teach that a resulting injury would not
have occurred to the patient if due care had been exercised, an inference of negligence may be drawn
giving rise to an application of the doctrine of res ipsa loquitur without medical evidence, which is
ordinarily required to show not only what occurred but how and why it occurred. When the
doctrine is appropriate, all that the patient must do is prove a nexus between the particular act or
omission complained of and the injury sustained while under the custody and management of the
defendant without need to produce expert medical testimony to establish the standard of care. Resort
to res ipsa loquitor is allowed because there is no other way, under usual and ordinary conditions, by
which the patient can obtain redress for injury suffered by him.
Thus, courts of other jurisdictions have applied the doctrine in the following situations: leaving of
a foreign object in the body of the patient after an operation, injuries sustained on a healthy part of the
body which was not under, or in the area, of treatment, removal of the wrong part of the body when
another part was intended, knocking out a tooth while a patient’s jaw was under anesthetic for the
removal of his tonsils, and loss of an eye while the patient was under the influence of anesthetic, during
or following an operation for appendicitis, among others.

We turn to the question whether petitioners have established specific acts of negligence
allegedly committed by respondent doctors.
First. While petitioners presented Dr. Apolinar Vacalares as an expert witness, we do not find him
to be so as he is not a specialist on infectious diseases like typhoid fever. Furthermore, although he
may have had extensive experience in performing autopsies, he admitted that he had yet to do one on
the body of a typhoid victim at the time he conducted the postmortem on Jorge Reyes. It is also plain
from his testimony that he has treated only about three cases of typhoid fever. He is thus not qualified
to prove that Dr. Marlyn Rico erred in her diagnosis. Both lower courts were therefore correct in discarding
his testimony, which is really inadmissible.
Second. On the other hand, the two doctors presented by respondents clearly were experts on
the subject. They vouched for the correctness of Dr. Marlyn Rico’s diagnosis. Dr. Peter Gotiong, a
diplomate whose specialization is infectious diseases and microbiology and an associate professor at
the Southwestern University College of Medicine and the Gullas College of Medicine, testified that he
has already treated over a thousand cases of typhoid fever. According to him, when a case of typhoid
fever is suspected, the Widal test is normally used, and if the1:320 results of the Widal test on Jorge
Reyes had been presented to him along with the patient’s history, his impression would also be that
the patient was suffering from typhoid fever. As to the treatment of the disease, he stated that
chloromycetin was the drug of choice. He also explained that despite the measures taken by
respondent doctors and the intravenous administration of two doses of chloromycetin, complications of
the disease could not be discounted. Though the Widal test is not conclusive, it remains a standard
diagnostic test for typhoid fever and, in the present case, greater accuracy through repeated testing
was rendered unobtainable by the early death of the patient. The results of the Widal test and the
patient’s history of fever with chills for five days, taken with the fact that typhoid fever was then prevalent
as indicated by the fact that the clinic had been getting about 15 to 20 typhoid cases a month, were
sufficient to give upon any doctor of reasonable skill the impression that Jorge Reyes had typhoid fever.
Third. Petitioners contend that respondent Dr. Marvie Blanes, who took over from Dr. Rico,
was negligent in ordering the intravenous administration of two doses of 500 milligrams of chloromycetin
at an interval of less than three hours. Petitioners claim that Jorge Reyes died of anaphylactic shock38
or possibly from overdose as the second dose should have been administered five to six hours after the
first, per instruction of Dr. Marlyn Rico. As held by the Court of Appeals, however: That chloromycetin
was likewise a proper prescription is best established by medical authority. Wilson, et. al., in
Harrison’s Principle of Internal Medicine, 12th ed. write that chlorampenicol (which is the generic of
chloromycetin) is the drug of choice for typhoid fever and that no drug has yet proven better in
promoting a favorable clinical response. "Chlorampenicol (Chloromycetin) is specifically indicated for
bacterial meningitis, typhoid fever, rickettsial infections, bacteriodes infections, etc." (PIMS Annual,
1994, p. 211) The dosage likewise including the first administration of five hundred milligrams (500
mg.) at around nine o’clock in the evening and the second dose at around 11:30 the same night was
still within medically acceptable limits, since the recommended dose of chloromycetin is one (1)
gram every six (6) hours. (cf. Pediatric Drug Handbook, 1st Ed., Philippine Pediatric Society,
Committee on Therapeutics and Toxicology, 1996). The intravenous route is likewise correct.
(Mansser,O’Nick, Pharmacology and Therapeutics) Even if the test was not administered by the
physician-on-duty, the evidence introduced that it was Dra. Blanes who interpreted the results remain
uncontroverted. (Decision, pp. 16-17). Once more, this Court rejects any claim of professional negligence
in this regard. As regards anaphylactic shock, the usual way of guarding against it prior to the
administration of a drug, is the skin test of which, however, it has been observed: "Skin testing with
haptenic drugs is generally not reliable. Certain drugs cause nonspecific histamine release, producing
a weal-and-flare reaction in normal individuals. Immunologic activation of mast cells requires a polyvalent
allergen, so a negative skin test to a univalent haptenic drug does not rule out anaphylactic sensitivity to
that drug." (Terr, "Anaphylaxis and Urticaria" in Basic and Clinical Immunology, p.349). What all this
means legally is that even if the deceased suffered from an anaphylactic shock, this, of itself,
would not yet establish the negligence of the appellee-physicians for all that the law requires of them
is that they perform the standard tests and perform standard procedures. The law cannot require them
to predict every possible reaction to all drugs administered.
Fourth, the practice of medicine is a profession engaged in only by qualified individuals. It is a
right earned through years of education, training, and by first obtaining a license from the state through
professional board examinations. Such license may, at any time and for cause, be revoked by the
government. In addition to state regulation, the conduct of doctors is also strictly governed by the
Hippocratic Oath, an ancient code of discipline and ethical rules which doctors have imposed upon
themselves in recognition and acceptance of their great responsibility to society. Given these safeguards,
there is no need to expressly require of doctors the observance of "extraordinary" diligence. As it is now,
the practice of medicine is already conditioned upon the highest degree of diligence. And, as we
have already noted, the standard contemplated for doctors is simply the reasonable average merit among
ordinarily good physicians. That is reasonable diligence for doctors or, as the Court of Appeals called it,
the reasonable "skill and competence . . . that a physician in the same or similar locality . . . should apply."